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Daybook, Reading notes

DSM-5 is not as user friendly as ICD-10.

One of my duties is to teach psychiatrists-in-training. In AUstralia and NZ, this is a five-year process that takes most people seven (or more) years: there are cases to write, experiences to log (which include quite a lot of talking therapy) and the technique and evidence for treating psychiatric disorders has to be formally taught.

And this led to a dilemma. I reviewed the draft of the DSM5 as a teacher, clinician, and someone who has spent around ten years involved in a large mental health survey. I’m also the local expert on anxiety disorders. I did not consider the proposed changes were warranted. So, for this year, I have deliberately changed the diagnostic system to the International Classification of Diseases. I still have concerns. Alan Frances (who worked on the previous version, which I consider reliable — but not that valid) notes there are still flaws.

Psychiatric diagnosis has become too important in selecting treatments, determining eligibility for benefits and services, allocating resources, guiding legal judgments, creating stigma, and influencing personal expectations to be left in the hands of an APA that has proven itself incapable of producing a safe, sound, and widely accepted manual.

New diagnoses in psychiatry are more dangerous than new drugs because they influence whether or not millions of people are placed on drugs- often by primary care doctors after brief visits. Before their introduction, new diagnoses deserve the same level of attention to safety that we devote to new drugs. APA is not competent to do this.

So, here is my list of DSM 5’s ten most potentially harmful changes. I would suggest that clinicians not follow these at all (or, at the very least, use them with extreme caution and attention to their risks); that potential patients be deeply skeptical, especially if the proposed diagnosis is being used as a rationale for prescribing medication for you or for your child; and that payers question whether some of these are suitable for reimbursement. My goal is to minimize the harm that may otherwise be done by unnecessary obedience to unwise and arbitrary DSM 5 decisions.

1) Disruptive Mood Dysregulation Disorder: DSM 5 will turn temper tantrums into a mental disorder- a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-times increase in Autistic Disorder, and a forty-times increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

2) Normal grief will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this ‘condition’ (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. Here the DSM 5 problem is not so much a bad decision, but the misleading promises that it will have no impact on rates of disorder or of service delivery. School services should be tied more to educational need, less to a controversial psychiatric diagnosis created for clinical (not educational) purposes and whose rate is so sensitive to small changes in definition and assessment.

7) First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Watch out for careless overdiagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

DSM 5 has dropped its pretension to being a paradigm shift in psychiatric diagnosis and instead (in a dramatic 180 degree turn) now makes the equally misleading claim that it is a conservative document that will have minimal impact on the rates of psychiatric diagnosis and in the consequent provision of inappropriate treatment. This is an untenable claim that DSM 5 cannot possibly support because, for completely unfathomable reasons, it never took the simple and inexpensive step of actually studying the impact of DSM on rates in real world settings.

Now, the ICD is a decade or so old, and a revision is in preparation. Due in 2016. The ICD does not have criteria, but instead clinical vignetters — which fits better with the way doctors thing (we use pattern recognition, and we do not sit and tick off criteria unless we are literally forced to) and the ICD 10 has less conditions, is more “lumpy”m and this is a feature, not a bug, given the current state of knowledge.

And since I don’t live in the USA, where insurance companies mandate the DSM, I don’t have to use it. Or teach it. Unless, of course, I’m involved in contract work for the US (read FDA) consumption. I will, however, add one thing. The diagnosis of Generalized Anxiety Disorder ahs changed so much from DSM-III that we need to do sensitivity analyses by diagnosis when reviewing papers for systematic review.

We do not need to change. Yet. We can wait for a few years. Besides, the ICD-10 is the official coding system in my nation already.


  1. pukeko Author

    Yeah, I have had a look, and it is about half right.
    And half wrong. There is no question among the early Christian writers that the martial virtues are to be honoured. But the Lordship and grasping for power and wealth that was also part of the Roman way — along with pederasty, tactical divorces, infanticide and the use of violence as entertainment for the dependant masses — was damned.
    on everything but the Christians refusal to worship the emperor, the Stoics and neoPlatonists found themselves with allies. The theolgians have technical words for this — around everyone knowing the law.
    What we have done over the last three generations (Boomers, X and millenials) is double down and double down again of feminism, which holds these virtues in contempt. We how have a second generation of men who do not know their fathers. And the ability — referring back to Sparta, which is what you were linking to — to stand, fight, and confront corruption (ie to have both physical and moral courage) is weaker.
    And, given your australian email, I suggest you consider the ALP of Gillard. No brains, no spine, no balls… and dog tucker by the end of the year. We do not want society to follow that path.

  2. pukeko Author

    Count your blessings. Key is not bad, but the idea of Sheep plus the Greens gives me the cold sweats.
    There is a reasonable choice between the centre (right) in NZ and OZ — because the green votes will be needed by Labo(u)r in both countries.
    And in the USA, Obama has become so fascist that again there is a clear choice.
    The times of tweedledum, tweedledee and King Log are, unfortunately, gone.

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